Tinnitus

• Tinnitus is abnormal ear noise.
• Tinnitus can arise in any of the four sections of the ear: the outer ear, the middle ear, the inner ear, and the brain.
• In addition to ringing in the ears, other symptoms associated with tinnitus may include:
  • Stress due to fear of tinnitus
  • Ear pain
  • Anxiety
  • Depression
  • Difficulty sleeping
  • Difficulty concentrating
  • Decreased hearing
• Persistent unexplained tinnitus is evaluated with a hearing test (audiogram).
• Measures can be taken to lessen the intensity of tinnitus.

Tinnitus is a symptom, not a disease, and it has a variety of causes that may arise anywhere in the hearing mechanism. It begins in the ear with the tympanic membrane and the cochlea, where sound is transmitted and transformed into electrical energy for the brain to perceive.

• Blood flow and/or tumors: Tinnitus that is throbbing (pulsatile) may be due to blood flow through arteries and veins adjacent to the ear, as well as tumors that are vascular, meaning that they have increased blood flow within them.
• Muscle spasms: Tinnitus that is described as clicking may be due to abnormalities that cause the muscle in the roof of the mouth (palate) to go into spasm. This causes the Eustachian tube, which helps equalize pressure in the ears, to repeatedly open and close. Multiple sclerosis and other neurologic diseases that are associated with muscle spasms may also be a cause of tinnitus, as they may lead to spasms of certain muscles in the middle ear that can cause the repetitive clicking.
• Temporomandibular joint (TMJ) abnormalities may cause a repeated clicking sound in the ear.
• Damage to the vestibulocochlear nerve: Damage to the vestibulocochlear nerve responsible for transmitting sound from the ear to the brain may cause tinnitus. Causes may include drug toxicity or a tumor (for example, acoustic neuroma).
• Meniere's disease, which is associated with hearing loss and vertigo also may cause tinnitus.
• Aging: As people age, their hearing may decrease and there can be associated tinnitus.
• Otosclerosis: Otosclerosis, which is caused by abnormal bone growth in the middle ear, can sometimes cause tinnitus.
• Trauma may also be a cause of tinnitus and hearing loss. This includes barotrauma, whereby air pressure changes can damage ear function. Examples of barotrauma include pressure changes from scuba diving or changes in air pressure when flying.

• The sound of tinnitus may be constant or it may come and go intermittently.
• It may be throbbing.
• It may occur in one ear or in both ears.
• Most often, the sound is a high pitched continuous tone, but it may also be described by the patient as a click, buzz, or a hum.
• Tinnitus is often associated with hearing loss and the patient may complain of decreased hearing, even if the tinnitus is absent.

Often tinnitus can be evaluated by a primary-care doctor or internist, but if consultation is needed, an otolaryngologist (ear, nose and throat doctor) is the specialist that evaluates and cares for people with tinnitus. Audiologists are trained to perform hearing tests and assessments.

The patient's history and description of symptoms is the key in determining what might be causing tinnitus.

The health-care professional may ask questions in regard to the quality of the abnormal sound, and whether it is constantly present or whether it comes and goes. Other questions may include the following:

• Does it involve one or both ears?
• Does the sound pulsate, or does it sound like a rush or flow?
• Does it click?
• Has there been recurrent exposure to loud noises or sound at work, at home or at play?
• Is there associated decreased hearing or hearing loss?
• Does the person feel a sensation of spinning (vertigo)?

Medications: Be prepared to provide the health-care professional a list of medications including over-the-counter (OTC) and supplements to review since tinnitus may be a side effect of certain medications.

Physical exam: Physical examination will focus on the head and neck, and especially the ears, including the auditory canals and tympanic membranes. Since the sense of hearing is conducted through one of the cranial nerves (the short nerves that lead directly from the brain to the face, head and neck), a careful neurologic exam also may be performed. Weakness or numbness in the face, mouth, and neck may be associated with a tumor or other structural abnormality pressing on a nerve. The healthcare professional may listen to the flow in the carotid arteries in the neck for an abnormal sound (bruit), since carotid artery stenosis (narrowing of the artery) can transmit a sound to the ear that may cause tinnitus.

Hearing test: An audiogram or hearing test may be performed to look for associated hearing loss in one or both ears.

Imaging: Depending upon the suspected underlying cause of tinnitus, radiology tests may be performed to image the head and neck, including the structures of the ear. These imaging tests may include CT scan, MRI and ultrasound.

Referral to a specialist: Consultation with the appropriate specialist may be needed, both for diagnosis and treatment.

Tinnitus is a common complaint, with up to 15% of Americans having experienced it. It is the most common symptom reported by military service members returning from combat.

• Tinnitus may last for weeks or months, and then resolve spontaneously. For some people tinnitus may last for years.
• The tinnitus may be significant enough to interfere with an individual's activities of daily living. For this reason, treatment must also be directed at decreasing the effects of tinnitus on a person's daily life, such as depression, insomnia, etc.
• For those people whose tinnitus is caused by an adverse or toxic reaction to a medication, stopping the drug may allow the hearing mechanism to recover; however, talk with your doctor before stopping any medication. Sometimes the adverse effects of medications on hearing may be permanent.
• Electrical stimulation and repetitive transcranial magnetic stimulation are some of the other treatment considerations available for certain individuals with tinnitus.

The following home remedies may be of benefit to some individuals with tinnitus.

• Dietary restrictions including avoiding caffeine and decreasing salt intake
• Smoking cessation
• Zinc supplements
• Melatonin
• Ginkgo biloba

• Benzodiazepine medications, including alprazolam (Xanax), may help suppress nerve function and decrease tinnitus symptoms.
• Corticosteroid injections into the middle ear may decrease inflammation in certain cases of tinnitus.
• Antidepressant medications may decrease the intensity of tinnitus or resolve the noise altogether. Moreover, antidepressants may also help with the depression that is sometimes associated with the presence of persistent and chronic tinnitus.
• Prostaglandin analogues, such as misoprostol (Cytotec), may be of some help in some people with tinnitus.

Surgery may be a cure for certain people who have:

• Meniere's disease (characterized by tinnitus, vertigo, and decreased hearing)
• Tinnitus due to glomus tumors
• Acoustic neuromas
• Sigmoid sinus diverticulum or arteriovenous malformations (AVMs)

There are some behavioral and cognitive therapies that have been successful in treating tinnitus. Seeking out a multidisciplinary program at a medical center that specializes in tinnitus may improve treatment success.

Tinnitus retraining therapy is a form of treatment that tries to retrain the nerve pathways associated with hearing that may allow the brain to get used to the abnormal sounds. Habituation allows the brain to ignore the tinnitus noise signal, and it allows the person to become unaware that it is present unless they specifically concentrate on the noise. This treatment involves counseling and wearing a sound generator. Audiologists and otolaryngologists often work together in offering this treatment.

In addition to tinnitus retraining therapy, other treatments exist which attempt to relieve tinnitus such as relief therapy, and each affected individual may benefit differently depending upon the cause of the tinnitus and their response to treatment. Some other treatment options include the following:

• Masking
• Biofeedback
• Stress reduction
• Depression counseling
• Electrical stimulation for patients with hearing loss

While scientific research has not shown the benefit of acupuncture in the treatment of tinnitus, there may be a significant positive placebo effect.

Repeated loud noise exposure can be a cause of tinnitus as well as hearing loss. Loud music may cause short term symptoms, but repeated occupational exposure (for example, musicians, factory and construction workers) requires less intense sound levels to cause potential hearing damage leading to tinnitus. Minimizing sound exposure, therefore, decreases the risk of developing tinnitus. Sound protection equipment, like acoustic ear-muffs, may be appropriate at work and at home when exposed to loud noises.

A variety of medications may be ototoxic (damage the ear) and cause tinnitus. If tinnitus develops while you are taking a medication, stop the medication and discuss other options with your health-care professional.

Tinnitus remains a symptom that affects the lives of millions of people. Research is directed not only at its treatment, but also at understanding why it occurs. Research by doctors at the University at Buffalo, The State University of New York, Dalhousie University (Canada), and Southeast China University have published research using electrophysiology and functional MRI to better understand what parts of the brain are involved in hearing and the production of tinnitus. Their research has found that much larger areas of the brain are involved with the process of hearing than previously believed, which may help direct future diagnostic and therapeutic options.